J Nutr Health Aging

OCCLUSAL SUPPORT, DYSPHAGIA, MALNUTRITION, AND ACTIVITIES

OF DAILY LIVING IN AGED INDIVIDUALS NEEDING LONG-TERM CARE:
A PATH ANALYSIS
H. WAKABAYASHI1,2, M. MATSUSHIMA2, H. ICHIKAWA2, S. MURAYAMA2, S. YOSHIDA2,
M. KANEKO2, R. MUTAI2
1. Department of Rehabilitation Medicine, Yokohama City University Medical Center, Minami ward, Yokohama city, Japan; 2. Division of Clinical Epidemiology, Jikei University
School of Medicine, Minato ward, Tokyo, Japan. Corresponding author: Hidetaka Wakabayashi, Department of Rehabilitation Medicine, Yokohama City University Medical Center,
4-57 Urafune-chou, Minami ward, Yokohama City, Japan 232-0024, E-mail: noventurenoglory@gmail.com, Tel: +81-45-261-5656; Fax: +81-45-253-9955

Abstract: Objectives: This study aimed to examine the interrelationships among occlusal support, dysphagia,
malnutrition, and activities of daily living in aged individuals needing long-term care. Design: Cross-sectional
study and path analysis. Setting: Long-term health care facilities, acute care hospitals, and the community.
Participants: Three hundred and fifty-four individuals aged ≥ 65 years with dysphagia or potential dysphagia in
need of long-term care. Measurements: The modified Eichner Index, Dysphagia Severity Scale, Mini Nutritional
Assessment Short Form, and Barthel index. Results: The participants included 118 males and 236 females with
a mean (standard deviation) age of 83 (8) years. A total of 216 participants had functional occlusal support with
or without dentures. Of the total participants, 73 were within normal limits regarding the severity of dysphagia,
119 exhibited dysphagia without aspiration, and 162 exhibited dysphagia with aspiration. Only 34 had a normal
nutritional status, while 166 participants were malnourished, and 154 were at risk of malnutrition. The median
Barthel index score was 30. Path analysis indicated two important findings: occlusal support had a direct effect
on dysphagia (standard coefficient = 0.33), and dysphagia was associated directly with malnutrition (standard
coefficient = 0.50). Dysphagia and malnutrition were associated directly with impaired activities of daily living
(standard coefficient = 0.57, 0.22). Conclusion: In aged individuals needing long-term care, occlusal support is
associated directly with dysphagia and indirectly with malnutrition and activities of daily living via dysphagia.

Key words: Deglutition disorders, dentures, nutritional status, oral health, rehabilitation.

Introduction receiving home care services. A smaller number of teeth was

Tooth loss is common in aged individuals and affects quality
of life, disabilities and mortality. The prevalence of severe tooth
loss increases around the seventh decade of life (1). In 2010,
158 million people worldwide were edentate (1). Tooth loss and
the number of occluding pairs of teeth affect oral health-related
quality of life (2). Furthermore, tooth loss is a risk factor for
disability onset and mortality in aged individuals (3). Therefore,
tooth loss and occlusal support in this population are important
public health issues.
The relationships among occlusal support, dysphagia,
malnutrition, and activities of daily living (ADLs) have
previously been evaluated. Tooth loss affects swallowing and
masticatory ability in aged individuals living independently
within the community (4). Dental occlusion is associated
with nutritional status (5, 6), ADLs (5), and physical
function (7), since loss of occlusal contact in natural teeth
affects micronutrient intake (8). Moreover, denture treatment
can improve the nutritional status (9), and occlusal support
is related to a better prognosis in older homebound adults
with higher ADLs (10). Therefore, occlusal support is likely
associated with dysphagia, malnutrition, and ADLs.
Furuta et al. (11) used path analysis to examine the
mechanistic pathways linking oral health status, swallowing
function, nutritional status and ADLs in aged individuals
Received July 29, 2016
Accepted for publication February 6, 2017
1
related positively to dysphagia, whereas wearing dentures
contributed to recovery of dysphagia. While dysphagia and
malnutrition decrease ADLs both directly and indirectly (11),
no studies have examined the interrelationships among occlusal
support, dysphagia, malnutrition, and ADLs in long-term health
care facilities and acute care hospitals. Furthermore, this earlier
study (11) did not assess swallowing function using dysphagia
severity scales. In the current study, our hypothesis was that
occlusal support is associated directly with dysphagia and
indirectly with malnutrition and ADLs via dysphagia.
This study aimed to examine the interrelationships among
occlusal support, dysphagia, malnutrition, and ADLs using
pathway analysis in aged individuals needing long-term care
in long-term health care facilities, acute care hospitals, or the
community.
Materials and methods
We performed a cross-sectional study in 354 Japanese
individuals aged ≥ 65 years in need of long-term care. The
participants were recruited from three long-term health care
facilities and one acute care hospital in the Tohoku region
and another acute care hospital in Yokohama from August to
December 2012. Japanese long-term care services are provided
by the Long-term Care Insurance Act. The Nursing Care
J Nutr Health Aging
OCCLUSAL SUPPORT, DYSPHAGIA, MALNUTRITION, AND ACTIVITIES OF DAILY LIVING
Authorization Screening Committee evaluates the level of
nursing care according to the authorization screening results
and doctors’ letters. All participants in the study were certified
as needing some level of nursing care. All participants from the
long-term health care facilities and acute care hospitals were
inpatients. Community-dwelling aged individuals with this
certification who were receiving home medical care were also
recruited.
The participants were recruited by research coworkers
through the Japanese Association of Rehabilitation Nutrition.
Individuals aged 65 years and older with certification of
needing long-term care and dysphagia or possible dysphagia
were included. Individuals with dementia or cognitive
impairment were also included. The exclusion criterion was
terminal-stage malignancy. All inpatients in three long-term
health care facilities and a community-based hospital at the time
of the investigation and who met the eligibility criteria were
enrolled in the study to reduce selection bias. The study was
approved by the ethics committee of Yokohama City University
Medical Center; no ethics committees exist at the other acute
care hospitals or long-term health care facilities participating
in this study. All participants or their legal representatives
provided informed consent. The study was performed in
accordance with the ethical standards of the 1964 Declaration of
Helsinki and its later amendments.
Twenty-four multi-disciplinary research coworkers (nurses,
physical therapists, occupational therapists, speech therapists,
registered dietitians, doctors, dental hygienists, and dentists)
collected the data at long-term health care facilities, acute care
hospitals, or the participants’ homes. Many of the research
coworkers are professionals certified by the Japanese Society
of Dysphagia Rehabilitation. To reduce bias in data collection
across the different settings, research coworkers specializing in
swallowing rehabilitation in routine medical care participated
in this study. Further, we formed a research committee to
discuss the collection of data obtained using standardized
questionnaires and implementation manuals. The characteristics
of the participants, such as age, sex, diseases, occlusal support,
dysphagia, nutritional status, and ADLs, were assessed by the
research coworkers.
Occlusal support was graded using the modified Eichner
Index (12), which is based on the occlusal contacts in both
the premolar and molar regions on each side. There are
four posterior support zones: the left molar, left premolar,
right premolar, and right molar regions. Occlusal contacts
are categorized into three classes. Class A includes occlusal
contacts in all four posterior support zones, class B includes
those in one to three posterior support zones or support in the
anterior teeth only, and class C is no occlusal contacts.
The participants in the study were classified into two groups
based on occlusal support function: the functional and non-
functional occlusal support groups. The former included those
with occlusal contacts in all four posterior support zones with
natural teeth or dentures (Eichner index class A), and the latter
2
group included those with occlusal contacts in zero to three
posterior support zones with natural teeth or dentures (Eichner
index classes B and C).
The dysphagia severity was evaluated by the 7-point
ordinal Dysphagia Severity Scale (DSS) (13). In this scale,
a score of 1 indicates saliva aspiration; 2, food aspiration; 3,
water aspiration; 4, occasional aspiration; 5, oral problems; 6,
minimal problems; and 7, within normal limits. Scores 5 and 6
imply dysphagia without aspiration and scores 1-4 dysphagia
with aspiration. The DSS has been assessed for inter-class
reliability and validity (14). One research coworker determined
the DSS score by observing eating abilities and conducting
bedside dysphagia screening tests including water swallowing
tests, food swallowing tests, cervical auscultation, and pulse
oximetry.
Nutritional status was evaluated by the Mini Nutritional
Assessment Short Form (MNA-SF) (15-17). The MNA-
SF includes six questions regarding decreased food intake,
weight loss, mobility, psychological stress or acute disease,
neuropsychological issues and body mass index. ADLs were
assessed by the Barthel index (18), which consists of the
following 10 items: 1) feeding, 2) moving back and forth
between a wheelchair and bed, 3) grooming, 4) moving to the
toilet, 5) bathing, 6) walking on a level surface, 7) moving
up and down stairs, 8) dressing, 9) bowel continence, and 10)
bladder continence.
The IBM Statistical Package for the Social Sciences (SPSS)
version 21 software and SPSS AMOS version 21 (IBM
Corporation; Armonk, NY, USA) were used for statistical
analyses. Parametric data are presented as means with standard
deviations and nonparametric data as medians and interquartile
ranges. The chi-square test, Mann-Whitney U test, and
Student’s t-test were performed to analyze differences between
participants with functional versus non-functional occlusal
support, participants with versus without cerebrovascular
disorders, and participants with versus without Parkinson’s
disease.
We performed a path analysis, a structural equation
modeling subset (19), to investigate the relationship between
occlusal support and the DSS, MNA-SF, and Barthel index.
As an extension of regression analysis, path analysis is used
to estimate the linear associations between all path variables
simultaneously (20), thereby making it possible to evaluate the
direct, indirect and total effects of each path variable. The direct
effect represents the effect not mediated through other variables
present in the pathway, the indirect effect represents the effect
mediated by other variables in the pathway, and the total effect
represents the direct and indirect effects combined.
First, we constructed a hypothetical model using manifest
variables from a previous publication (Figure 1) (11). We
then tested alternative path models until goodness-of-fit was
obtained. Potential confounders were age, sex, and setting.
The goodness-of-fit test criteria included a chi-square test,
goodness of fit index (GFI), adjusted goodness of fit index
J Nutr Health Aging

THE JOURNAL OF NUTRITION, HEALTH & AGING©

Table 1
Characteristics of participants, occlusal support, dysphagia, nutritional status, and ADL in aged individuals needing long-term
care and were living in long-term health care facilities, acute care hospitals, or the community

Total LHCF AH CD
Age, y
Mean (SD) 83 (8) 85 (8) 82 (8) 81 (8)
Gender, n (%)
Male 118 (33) 39 (22) 25 (39) 54 (47)
Female 236 (67) 137 (78) 39 (61) 60 (53)
Occlusal support, n (%)
Non-functional 138 (39) 101 (57) 16 (25) 21 (18)
Functional 216 (61) 75 (43) 48 (75) 93 (82)
DSS, n (%)
1 23 (7) 14 (8) 5 (8) 4 (4)
2 35 (10) 19 (11) 13 (20) 3 (3)
3 48 (14) 27 (15) 8 (13) 13 (11)
4 56 (16) 31 (18) 12 (19) 13 (11)
5 48 (14) 34 (19) 4 (6) 10 (9)
6 71 (20) 37 (21) 21 (33) 13 (11)
7 73 (21) 14 (8) 1 (2) 58 (51)
MNA-SF score, n (%)
Malnourished 166 (47) 90 (51) 46 (72) 30 (26)
At risk of malnutrition 154 (44) 76 (43) 17 (27) 61 (54)
Normal nutritional status 34 (10) 10 (6) 1 (2) 23 (20)
Barthel index
Median (interquartile range) 30 (5-66) 10 (0-40) 15 (0-54) 74 (35-85)
LHCF, long-term health care facilities; AH, acute care hospitals; CD, community-dwelling; DSS, Dysphagia Severity Scale; MNA-SF, Mini Nutritional Assessment Short Form

(AGFI), normed fit index (NFI), comparative fit index (CFI),
Tucker-Lewis index (TLI), and a root mean square error of
approximation (RMSEA). A p-value > 0.05 obtained by chi-
square test, GFI and AGFI values > 0.90, NFI, CFI, and TLI
values > 0.95, and RMSEA values < 0.05 were determined to
indicate a good fit. A p-value < 0.05 was considered statistically
significant.
Results
A total of 216 (61%) participants had functional occlusal
support with or without dentures. Older individuals living
in long-term health care facilities had less occlusal support
than did those in acute care hospitals or the community. DSS
assessment showed that 73 (21%) participants were within
normal limits, 119 (34%) had dysphagia without aspiration,
and 162 (46%) had dysphagia with aspiration. Based on the
MNA-SF, 166 (47%) participants were malnourished, 154
(44%) were at risk of malnutrition, and 34 (10%) had a normal
nutritional status. Age, setting, the DSS, MNA-SF, and Barthel
3DUWLFLSDQWV LQFOXGHG  RI   HOLJLEOH DJHG •  index scores were significantly different between the functional
years) individuals, with a mean (standard deviation) age of 83 versus non-functional occlusal support groups (Table 2). Age,
(8) years; 3 individuals from the acute care hospitals declined to sex, and the DSS and Barthel index scores were significantly
participate in the study. Common diseases were cerebrovascular different between participants with and those without
disorders (n=198, 56%), chronic heart failure (n=62, 18%), cerebrovascular disorders (Table 3). The MNA-SF and Barthel
respiratory diseases (n=37, 10%), Parkinson’s disease (n=36, index scores were significantly different between participants
10%), and cancer (n=21, 6%). Table 1 summarizes the rates with and those without Parkinson’s disease (Table 3).
of occlusal support, dysphagia, nutritional status, and ADLs in No data were missing in the path analysis. First, we
long-term health care facilities, acute care hospitals, and the constructed a model containing all hypothesized pathways.
community. Then, variables that showed significant bivariate correlations
3
J Nutr Health Aging

OCCLUSAL SUPPORT, DYSPHAGIA, MALNUTRITION, AND ACTIVITIES OF DAILY LIVING

were incorporated and the insignificant pathways omitted. A G\VSKDJLDDQGPDOQXWULWLRQWR$'/Vơ DQG

final model was constructed based on only the statistically
significant pathways. The final goodness-of-fit model was
deemed excellent (chi-square = 3.464, p = 0.483; GFI =
0.996; AGFI = 0.985; NFI = 0.993; CFI = 1.000; TLI = 1.003;
RMSEA < 0.001).
Table 2
t-test, chi-square test, and Mann-Whitney U test of
differences between individuals with and without functional
occlusal support in aged individuals needing long-term care
respectively, all p-values < 0.001). The total effect of living in
long-term health care facilities, dysphagia, and malnutrition on
ADLs was 0.60. On the other hand, occlusal support was not
associated directly with either malnutrition or ADLs. However,
occlusal support was associated indirectly with malnutrition and
ADLs via dysphagia. Age and sex were not selected in the final
path model.
Figure 1
The hypothesized model

Occlusal support
Non-functional Functional P-value
n = 138 n = 216
Age, y , mean (SD) 85 (8) 82 (8) 0.0021)
Gender, n (%) 0.1062)
Male 39 (28) 79 (37)
Female 99 (72) 137 (63)
The hypothesized model. The model consists of four manifest variables including occlusal
Diagnosis of diseases, n (%)
support, dysphagia, malnutrition, and activities of daily living.
Cerebrovascular disorders 83 (60) 115 (53) 0.2022)
Chronic heart failure 20 (14) 42 (19) 0.2322) Figure 2
Respiratory diseases 12 (9) 25 (12) 0.3882) The final model
Parkinson’s disease 12 (9) 24 (11) 0.4632)
Cancer 9 (7) 12 (6) 0.7072)
Setting, n (%) <0.0012)
Long-term health care facilities 101 (73) 75 (35)
Acute care hospitals 16 (12) 48 (22)
Community 21 (15) 93 (43)
DSS, n (%) <0.0013)
1 19 (14) 4 (2) The final model consists of five manifest variables including long-term health care
facilities, occlusal support, dysphagia, malnutrition and activities of daily living. The
2 19 (14) 16 (7) standardized coefficients between variables are given. All p-values are < 0.001.
3 24 (17) 24 (11)
4 22 (16) 34 (16) Discussion
5 22 (16) 26 (12)
This study addressed the interrelationships among occlusal
6 18 (13) 53 (25)
support, dysphagia, malnutrition, and ADLs in aged individuals
7 14 (10) 59 (27)
in need of long-term care. The findings showed that occlusal
MNA-SF score, n (%) 0.0042)
support was 1) associated directly with dysphagia and 2) was
Malnourished 77 (56) 89 (41) not associated directly, but rather indirectly, with malnutrition
At risk of malnutrition 55 (40) 99 (46) and ADLs via dysphagia.
Normal nutritional status 6 (4) 28 (13) Occlusal support was associated directly with dysphagia
Barthel Index, median (interquartile range) 8 (0-40) 45 (10-75) <0.0013) in aged individuals requiring long-term care. This result is
1) t-test, 2) chi-square test, 3) Mann-Whitney U test; DSS, Dysphagia Severity Scale; similar to those of previous studies (4, 11). Occlusal support
MNA-SF, Mini Nutritional Assessment Short Form affects both mastication and swallowing functions, as chewing
movements are necessary to eat solid food. Therefore,
Figure 2 shows the final path model. These were significant encouraging denture wearing to achieve occlusal support when
direct pathways: (1) from long-term health care facilities to teeth are missing is important to improve swallowing function.
RFFOXVDO VXSSRUW >ơ VWDQGDUGL]HG FRHIILFLHQW   SYDOXH In our study, the associations between occlusal support and
 @  IURP RFFOXVDO VXSSRUW WR G\VSKDJLD ơ   nutritional status and ADLs were indirect. Modification of
SYDOXHIURPG\VSKDJLDWRPDOQXWULWLRQơ  food texture may be one reason that occlusal support was not
p-value < 0.001); and (4) from long-term health care facilities, associated directly with malnutrition, because foods modified to

4
J Nutr Health Aging

THE JOURNAL OF NUTRITION, HEALTH & AGING©

Table 3
t-test, chi-square test, and Mann-Whitney U test of differences between individuals with and without cerebrovascular disorders and Parkinson’s
disease

Cerebrovascular disorders Parkinson’s disease

Presence Absence P-value Presence Absence P-value
n = 198 n = 156 n = 36 n = 318
Age, y , mean (SD) 82 (8) 84 (8) 0.0131) 82 (8) 83 (8) 0.4921)
Gender, n (%) 0.0012) 0.7092)
Male 81 (41) 37 (24) 11 (31) 107 (34)
Female 117 (59) 119 (76) 25 (69) 211 (66)
DSS, n (%) <0.001 3)
0.0823)
1 12 (6) 11 (7) 5 (14) 18 (6)
2 29 (15) 6 (4) 4 (11) 31 (10)
3 25 (13) 23 (15) 6 (17) 42 (13)
4 46 (23) 10 (6) 8 (22) 48 (15)
5 22 (11) 26 (17) 4 (11) 44 (14)
6 41 (21) 30 (19) 8 (22) 63 (20)
7 23 (12) 50 (32) 1 (3) 72 (23)
MNA-SF score, n (%) 0.297 2)
<0.0012)
Malnourished 100 (51) 66 (42) 28 (78) 138 (43)
At risk of malnutrition 81 (41) 73 (47) 8 (22) 146 (46)
Normal nutritional status 17 (9) 17 (11) 0 (4) 34 (11)
Barthel Index, median (interquartile range) 15 (0-55) 45 (10-80) <0.001 3)
5 (0-42.5) 30 (5-70) 0.0033)
1) t-test, 2) chi-square test, 3) Mann-Whitney U test; DSS, Dysphagia Severity Scale; MNA-SF, Mini Nutritional Assessment Short Form

puréed or jellied textures are safe to swallow without chewing.
Lower median Barthel index scores may be one reason that
the association between occlusal support and ADLs was not
direct. For example, individuals who were independent in their
feeding, grooming and continence abilities, but not other ADLs,
had a Barthel index score of 35. In this study, the median
Barthel index score was 30, indicating that many of the aged
individuals in this study could not walk independently. Occlusal
support may be important for walking on a level surface and
moving up and down stairs. However, occlusal support may not
be important for grooming or bowel/bladder continence.
The associations between dysphagia and malnutrition and
ADLs were comparatively strong, according to the relatively
KLJKơYDOXHVIURPG\VSKDJLDWRPDOQXWULWLRQDQG$'/VLQWKH
final path model. Furthermore, poor oral status was found to be
associated with sarcopenia, undernutrition, and ADLs in older
individuals (21). Therefore, encouraging denture wearing to
achieve occlusal support when teeth are missing may ameliorate
nutritional status and ADLs via improved swallowing function.
Living in long-term health care facilities was associated
directly with occlusal support and ADLs in this study. Eligible
users of long-term health care facilities are aged individuals
with illnesses that do not necessitate hospitalization, but do
require rehabilitation or other care. Therefore, the ADLs of
these individuals are more impaired than the ADLs of those
living in other settings. Dental consultation may be more
difficult in long-term health care facilities. However, dental
consultation and encouraging denture wearing to achieve
occlusal support are important factors.
The strengths of the study were its multi-institutional design,
use of a comprehensive dataset, and the lack of inter-tester
errors due to use of only one assessor. The study may have
higher external reliability, because all of the involved research
coworkers specialize in dysphagia rehabilitation, and because
standardized questionnaires and implementation manuals were
used.
The study had a few limitations. Firstly, information bias
may have occurred during evaluation of occlusal support
and the DSS, MNA-SF and Barthel index, because all these
measures were evaluated by the same research coworker.
Secondly, it is difficult to establish causality in a cross-sectional
study, although causal inferences about interrelationships can
be drawn from path analysis. Finally, we could not demonstrate
inter-rater reliability for assessment of occlusal support,
dysphagia severity, nutritional status, or ADLs. However, many
of the research coworkers are professionals certified by the
Japanese Society of Dysphagia Rehabilitation.
In conclusion, occlusal support is associated directly

5
J Nutr Health Aging
OCCLUSAL SUPPORT, DYSPHAGIA, MALNUTRITION, AND ACTIVITIES OF DAILY LIVING
with dysphagia and indirectly with malnutrition and ADLs
via dysphagia in aged individuals needing long-term care.
Encouraging denture wearing to achieve occlusal support when
teeth are missing may ameliorate nutritional status and ADLs
via improved swallowing function. Future studies evaluating
the effects of oral management and denture treatment should
assess dysphagia, sarcopenia, malnutrition, and ADLs
simultaneously and independently.
Acknowledgements: This study was supported by a Grant-in-Aid for the
Comprehensive Research on Aging and Health from the Ministry of Health, Labor, and
Welfare of Japan, and a research Grant-in-Aid for Scientific Research C (no. 16K01460)
from the Ministry of Education, Science, Culture, Sports, Science, and Technology of
Japan. The authors acknowledge the research collaborators and the Japanese Association of
Rehabilitation Nutrition for their contributions to the data collection.
Disclosure statement: Dr. Wakabayashi received grants from the Ministry of Health,
Labor, and Welfare of Japan to conduct this study, as well as grants from the Ministry
of Education, Culture, Sports, Science, and Technology of Japan and a grant from Nestlé
Health Sciences, outside of the submitted work. Dr. Matsushima, Dr. Ichikawa, Dr.
Murayama, Dr. Yoshida, Dr. Kaneko, and RN Mutai have nothing to disclose.
Ethical standards: The study was approved by the ethics committee of Yokohama City
University Medical Center. This study complies with the Japanese ethical guidelines for
epidemiological research.
References
1. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global
burden of severe tooth loss: a systematic review and meta-analysis. J Dent Res
2014;93:20S-28S. doi: 10.1177/0022034514537828.
2. Gerritsen AE, Allen PF, Witter DJ, Bronkhorst EM, Creugers NH. Tooth loss and
oral health-related quality of life: a systematic review and meta-analysis. Health Qual
Life Outcomes 2010;8:126. doi: 10.1186/1477-7525-8-126.
3. Holm-Pedersen P, Schultz-Larsen K, Christiansen N, Avlund K. Tooth loss and
subsequent disability and mortality in old age. J Am Geriatr Soc 2008;56:429-435.
doi: 10.1111/j.1532-5415.2007.01602.x.
4. Okamoto N, Tomioka K, Saeki K, Iwamoto J, Morikawa M, Harano A, Kurumatani
N. Relationship between swallowing problems and tooth loss in community-dwelling
independent elderly adults: the Fujiwara-kyo study. J Am Geriatr Soc 2012;60:849-
853. doi: 10.1111/j.1532-5415.2012.03935.x.
5. Kikutani T, Yoshida M, Enoki H, Yamashita Y, Akifusa S, Shimazaki Y, Hirano
H, Tamura F. Relationship between nutrition status and dental occlusion in
community-dwelling frail elderly people. Geriatr Gerontol Int 2013;13:50-54. doi:
10.1111/j.1447-0594.2012.00855.x.
6. Mesas AE, Andrade SM, Cabrera MA, Bueno VL. Oral health status and nutritional
deficit in noninstitutionalized older adults in Londrina, Brazil. Rev Bras Epidemiol
2010;13:434-445.
7. Yamaga T, Yoshihara A, Ando Y, Yoshitake Y, Kimura Y, Shimada M, Nishimuta
M, Miyazaki H. Relationship between dental occlusion and physical fitness in an
elderly population. J Gerontol A Biol Sci Med Sci 2002;57:M616-620.
8. Yoshida M, Kikutani T, Yoshikawa M, Tsuga K, Kimura M, Akagawa Y. Correlation
between dental and nutritional status in community-dwelling elderly Japanese. Geriatr
Gerontol Int 2011;11:315-319. doi: 10.1111/j.1447-0594.2010.00688.x.
9. Kanehisa Y, Yoshida M, Taji T, Akagawa Y, Nakamura H. Body weight and serum
albumin change after prosthodontic treatment among institutionalized elderly in a
long-term care geriatric hospital. Community Dent Oral Epidemiol 2009;37:534-538.
doi: 10.1111/j.1600-0528.2009.00496.x.
10. Suzuki R, Kikutani T, Yoshida M, Yamashita Y, Hirayama Y. Prognosis-related
factors concerning oral and general conditions for homebound older adults in Japan.
Geriatr Gerontol Int 2015;15:1001-1006. doi: 10.1111/ggi.12382.
11. Furuta M, Komiya-Nonaka M, Akifusa S, Shimazaki Y, Adachi M, Kinoshita T,
Kikutani T, Yamashita Y. Interrelationship of oral health status, swallowing function,
nutritional status, and cognitive ability with activities of daily living in Japanese
elderly people receiving home care services due to physical disabilities. Community
Dent Oral Epidemiol 2013;41:173-181. doi: 10.1111/cdoe.12000.
12. Eichner K. Renewed examination of the group classification of partially edentulous
arches by Eichner and application advices for studies on morbidity statistics. Stomatol
DDR 1990;40:321-325. [Article in German]
13. Wakabayashi H, Matsushima M. Neck circumference is not associated with
dysphagia but with undernutrition in elderly individuals requiring long-term care. J
Nutr Health Aging 2016;20:355-360. doi: 10.1007/s12603-015-0587-8.
14. Wakabayashi H, Matsushima M. Dysphagia assessed by the 10-item Eating
Assessment Tool is associated with nutritional status and activities of daily living in
elderly individuals requiring long-term care. J Nutr Health Aging 2016;20:22-27. doi:
10.1007/s12603-015-0481-4.
15. Vellas B, Villars H, Abellan G, Soto ME, Rolland Y, Guigoz Y, Morley JE, Chumlea
W, Salva A, Rubenstein LZ, Garry P. Overview of the MNA® - its history and
challenges. J Nutr Health Aging 2006;10:456-465.
16. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for
undernutrition in geriatric practice: developing the Short-Form Mini Nutritional
Assessment (MNA-SF). J Geront 2001;56A:M366-M372.
17. Guigoz Y. The Mini-Nutritional Assessment (MNA®) review of the literature - what
does it tell us? J Nutr Health Aging 2006;10:466-487.
18. Mahoney FI, Barthel D. Functional evaluation: the Barthel Index. Md State Med J
1965;14:61-65.
19. Bentler PM, Stein JA. Structural equation models in medical research. Stat Methods
Med Res 1992;1:159-181.
20. Gamborg M, Andersen PK, Baker JL, Budtz-Jørgensen E, Jørgensen T, Jensen G,
Sørensen TI. Life course path analysis of birth weight, childhood growth, and adult
systolic blood pressure. Am J Epidemiol 2009;169:1167-1178. doi: 10.1093/aje/
kwp047.
21. Shiraishi A, Yoshimura Y, Wakabayashi H, Tsuji Y. Poor oral status is associated
with rehabilitation outcome in older people. Geriatr Gerontol Int 2016;doi: 10.1111/
ggi.12763.